Commentary on: Labia Minora, Labia Majora, and Clitoral Hood Alteration: Experience-Based Recommendations

It is with great pleasure that we discuss “Labia Minora, Labia Majora, and Clitoral Hood Alteration: Experience-Based Recommendations,” by Dr John G. Hunter.1 In this article, Dr Hunter provides pragmatic information on performing labia minora, clitoral hood, and labia majora surgery based on his observations and experience performing these procedures. Although more and more articles are being published covering topics in female cosmetic genital surgery, most focus on specific techniques or outcomes related to safety.2-5 In this article, Dr Hunter dives deeper into the subtleties of technique selection based on patient characteristics—the finesse of aesthetic plastic surgery. Dr Hunter outlines significant and subtle differences between the three most commonly performed approaches for labiaplasty: edge excision, wedge excision, and central excision/deepithelialization, and these are summarized in Table 1. He underscores the importance of addressing clitoral hood redundancy (if present) at the time of labiaplasty to avoid creating a disproportionate and unnatural-appearing vulva. Additionally, Dr Hunter discusses some important issues concerning labia majora reduction. In women desiring augmentation, fat grafting is a good tool, but conservative volumes should be used. However, if significant ptosis or deflation is present, he recommends reduction of excess tissue by excision. Dr Hunter discusses several perioperative considerations in this article. He performs most labiaplasty procedures using local anesthetic and mild oral sedation. He outlines how he uses topical anesthetic followed by local anesthetic to achieve adequate patient comfort during the procedure. When performing multiple procedures, it is his preference to perform labia majora modification first, followed by clitoral hood reduction, and then labia minora excision. We recently published our experience with an edge excision technique for labiaplasty in 113 patients.4 We use this technique because it is straightforward to adapt and provides safe and consistent outcomes. The surgical technique is versatile and can be modified to address most shapes and sizes of labia minora. Dr Hunter points out some of the limitations with this technique including the potential for overresection, scalloping of the wound edges, and difficulty preserving pigmented skin when desired by the patient. In our article, we also underscore the importance of a conservative reduction as further surgery for additional removal of tissue can be performed with minimal difficulty, whereas treatment of labia minora overresection is very problematic.4 Scalloping of the wound edges can be avoided by precise closure and removal of any sutures that persist beyond 2 weeks postoperatively. In our experience, many patients desire removal of the darkly pigmented labia minora skin during labiaplasty. However, a wedge excision technique may be more suitable to preserve pigmented skin for patients that desire this, as Dr Hunter points out in his article. Although much of the early attention towards female cosmetic genital surgery focused on complications,6,7 Dr Hunter highlights that complication rates are very low, and most of these tend to be minor and self-limited. He points out that he has never observed persisting postoperative dyspareunia in his patients. Our experience has been similar; complications are exceptionally rare, and dyspareunia does not appear to be a common issue in women presenting for cosmetic genital surgery.4 This may be due to differences in patient demographics between those presenting to a plastic surgery practice for cosmetic improvement compared with those presenting to a gynecologic practice with functional complaints. In Dr Hunter's experience, as well as our own, labiaplasty is performed for cosmetic improvement in the overwhelming majority of women as opposed to functional indications. Similar to other aesthetic surgery procedures, a woman seeking labiaplasty is often unhappy with the appearance of the area, and she desires an improvement in the overall appearance despite having anatomy that is within the spectrum of ‘normal’ appearance. She is typically self-motivated in her decision to undergo an aesthetic plastic surgery procedure, and she desires a change to create an appearance that she will feel is more congruent with what she perceives to be attractive. Recent articles by Oranges et al2 and Motakef et al3 provide extensive literature reviews and also conclude that labiaplasty is safe and is associated with high patient satisfaction rates. In summary, this article by Dr Hunter adds to the growing literature describing not only the objective outcomes as they relate to the safety of cosmetic genital surgery, but the subtleties of these types of surgery, which will help evolve techniques so that we can provide the optimal aesthetic outcome that our patients desire. The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The authors received no financial support for the research, authorship, and publication of this article.

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